FoodShare Forms

Clicking the Assigned Number link will either download the selected form (if only one version is available) OR it will open a page that will display all language versions of that form. From that page you can choose and download the needed forms.
Assigned Numbersort descending Title Division Other Location
F-00098 Summary of Information Letter (PDF, 224 KB) DHCAA
F-00107 Self-Employment Income Report (PDF, 91 KB) DHCAA
F-00107W Self-Employment Income Report Worksheet (PDF, 32 KB) DHCAA
F-00136 FoodShare Employment and Training (FSET) Participation Agreement (PDF, 368 KB) DHCAA
F-00219 Self-Employment Income Report - Farmer DHCAA
F-00219W Self-Employment Income Report - Farmer Worksheet (PDF, 32 KB) DHCAA
F-00330 Request for Replacement FoodShare Benefits (PDF, 28 KB) DHCAA
F-00363 FoodShare Renewal Request for a Closed Case DHCAA
F-00628 Consortium Response to the State IM Second Party Review Finding DHCAA
F-01252 FoodShare Employment and Training - Initial Appointment Letter DHCAA
F-01253 FoodShare Employment and Training - Final Notice Appointment Letter DHCAA
F-01254 FoodShare Employment and Training - Employment Plan (EP) Appointment Letter DHCAA
F-01255 FoodShare Employment and Training - Job Club Appointment Letter DHCAA
F-01256 FoodShare Employment and Training - Discuss Participant Appointment Letter DHCAA
F-01257 FoodShare Employment and Training - Workshop Appointment Letter DHCAA
F-01359 Historical Earnings Verification Request DHCAA
F-01567 Long-Term Care Insurance Policy – Assignment of Benefits DHCAA
F-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 539 KB) DHCAA
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application (PDF, 654 KB) DHCAA
F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (PDF, 148 KB) DHCAA
F-10144 Life Insurance Inquiry DHCAA
F-10146 Employment Verification of Earnings DHCAA
F-10150 Your Rights and Responsibilities for Health Care / FoodShare (PDF, 81 KB) DHCAA
F-10150B Your Rights and Responsibilities for FoodShare DHCAA
F-16001 Negative Notice DHCAA
F-16004 Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits (PDF, 32 KB) DHCAA
F-16006 FoodShare Wisconsin Change Report DHCAA
F-16011 Quality Assurance (QA) Sample Check List (PDF, 226 KB) DHCAA
F-16014 Notice of Program Violation (PDF, 43 KB) DHCAA
F-16015 Positive Notice DHCAA
F-16019A FoodShare Wisconsin Registration / Important Information DHCAA
F-16019B FoodShare Wisconsin Application / Registration DHCAA
F-16022 Social Security Number Referral (PDF, 61 KB) DHCAA
F-16023 Striker Evaluation (PDF, 395 KB) DHCAA
F-16024 Notice of Disqualification (PDF, 110 KB) DHCAA
F-16025 Disqualification Consent Agreement (PDF, 71 KB) DHCAA
F-16026 Prosecution Diversion Agreement (PDF, 251 KB) DHCAA
F-16028 Notice of FoodShare Over issuance (PDF, 288 KB) DHCAA
F-16029 FoodShare Wisconsin Repayment Agreement (PDF, 108 KB) DHCAA
F-16030 FoodShare Wisconsin Under / Over Issuance Worksheet (PDF, 35 KB) DHCAA
F-16033 FoodShare Worksheet (PDF, 45 KB) DHCAA
F-16034 Self-Employment Income Worksheet - Corporation (PDF, 25 KB) DHCAA
F-16035 Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 28 KB) DHCAA
F-16036 Self-Employment Income Worksheet - Partnership (PDF, 27 KB) DHCAA
F-16037 Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business (PDF, 34 KB) DHCAA
F-16037A Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business for Magi Based Assistance Groups (PDF, 43 KB) DHCAA
F-16038 Administrative Disqualification Hearing Notice (PDF, 101 KB) DHCAA
F-16039 Waiver of Administrative Disqualification Hearing (PDF, 141 KB) DHCAA
F-16050 Agency Response to the State Quality Assurance (QA) FoodShare (FS) Finding (PDF, 183 KB) DHCAA
F-16060 Disaster FoodShare Wisconsin Assistance Application DHCAA

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Last Revised: December 23, 2014